Thursday, July 31, 2014

I am not my pain. I am a wife, mother, worker, writer, sister, daughter
and friend. My world is rich and rewarding. I want for nothing – save
pain relief. In fact, although the pain may be a permanent fixture, the sensation is impermanent. Some days are better than others. I must choose how much I want to let
it control my experience—or how much I want to control it.

Wednesday, July 30, 2014

With great disappointment, I sadly announce that
“A Reason To Ride’s” founder, Tom DesFosses’ cancer is back. While Tom
started to "A Reason to Ride" because he wanted to give back and raise
funds for research he never made the Ride about himself. Tom founded
the ride because many of us have reasons to ride. His energy and enthusiasm persuaded me to give full logistical support to the ride when I was running the hospital. Now, the ride is run solely by Tom and his friends, with tremendous support from Fuddruckers restaurants and the other firms noted below.

We still have reasons
to ride, and it’s never been more important than now to ride. I hope you'll join me on September 7 in Danvers, MA. Here is
Tom in his own words:

Why A Reason To Ride? I have a new reason, personal as it is. I have
just been re-diagnosed with brain cancer. This year was to be my 10th
year cancer free, but alas it came back in spades. A few weeks ago I
visited BIDMC for my yearly check up and a MRI. For the past nine years
we looked at the MRI and smiled and then said "See you next year." Not so
this time, the cancer has returned BIG time. Since that Thursday my life
has been a blur: Thursday blood work, Friday more MRI’s and body scans,
Monday spinal tap, Tuesday out-patient chemo, Wednesday in patient
chemo, released Sunday, sick and tired as hell up to Thursday, start the
whole process again next Tuesday for at least 4 more times. Then what,
probably every other month for a year and a half, then?

If you’re wondering if I am upset, sure I am, because most of the
research funding is raised by groups like ours and we don’t have the
full support Federally to fund all the medical research necessary to
find a cure. This is why I started the event and why your support is so
important to OUR fight.

Finally, I’m asking for your help, not for me, but for our future.
Please forward this email to your friends, ask them to ride, ask them to
donate and spread the message. Yell out your reason to ride and join
us on September 7 as we fight cancer together.

Gary Schwitzer offers a front-row seat to some conflicting claims. It all starts with a news release from robotic surgeon David Samadi at New York's Lenox Hill Hospital that was picked up by the American Urological Association (AUA):

According to a new study from Detroit, Michigan, robotic
prostatectomy yields highly successful long-term prostate cancer
results. In fact, nearly all — 98.8% — of the patients remained prostate
cancer survivors at ten years post-surgery; results comparable to the
more invasive surgical method used in the past.

Oncologist Richard Hoffman replies:

“The AUA does misrepresent the data. The 98.8% refers to the
proportion of subjects who had not died from prostate cancer. Only
73.1% were biochemically free of cancer, meaning that the rest had a
rising PSA suggesting cancer progression/recurrence.

The observational design means that investigators cannot make any
meaningful comparisons of robotic surgery results with those obtained
by open prostatectomy, Thus, Samadi’s comment that robotic
prostatectomy is “a preferred treatment” is not based on convincing
evidence, just on the “preferences” of surgeons and patients who see the
surgeons’ ads.

Them's fighting words! Gary says, "Let’s see how the urologists duke it out." One already expressed some thoughts on Twitter.

A friend of mine was excitedly discussing her job with a high-tech firm. "Our meetings are so great and vibrant. While the sessions are going on, we are all on our computers multi-tasking. It's so efficient!"

Well, no. There's a lot of evidence that constant interruptions do not improve efficiency and that they also impair quality. Here's a recent example, published in Human Factors. It focused solely on interruptions during the course of writing and concluded:

Our research
suggests that interruptions negatively impact quality of work during a complex, creative writing task.

Brad Flansbaum offers this interesting post about the ambiguities and uncertainties inherent in the current Medicare "two-midnight rule." He refers to a recent white paper prepared by a group of hospitalists:

Months of work have led us to our white paper, entitled, The Observation Status Problem: Impact and Recommendations for Change.
The release utilizes a multidimensional data set of significant size
and includes a finding synthesis. It is our hope to use the information
we collected to inform Congress, CMS, media, and members on the
somewhat chaotic understanding of observation status policy.

This is well done and thoughtful and could be of assistance to federal policy makers, if they take the time to read and listen. Look at this portion of the introduction:

The intricacies of observation policy have created a situation where observation care is now commonly
being delivered on hospital wards, indistinguishable from inpatient care. The frequency and duration of
observation status has also grown significantly in recent years, well beyond its original intent. This is important
because observation is not covered by Medicare Part A hospital insurance, and patients under observation are
ineligible for skilled nursing facility (SNF) coverage at discharge, which may leave them vulnerable to
additional complications.

The results:

--Lack of knowledge and confidence in implementing the two-midnight rule--Disruptions to hospitalist and hospital workflow--Decrease in the ability of hospitalists to make independent clinical decisions--Negative impacts on patients, including access to SNF coverage and highly variable financial liabilities --Damage to the physician-patient relationship

Tuesday, July 29, 2014

Earlier this month, Modern Healthcare published a story about the slow movement by hospitals to prevent operating room fires. An excerpt:

Despite a slew of news accounts about patients being set on fire in
operating rooms across the country, adoption of precautionary measures
has been slow, often implemented only after a hospital experiences an
accident. Advocates say it's not clear how many hospitals have
instituted the available protocols, and no national safety authority
tracks the frequency of surgical fires, which are thought to injure
patients in one of every three incidents. About 240 surgical fires occur
every year, according to rough estimates by the ECRI Institute, a not-for-profit organization that conducts research on patient-safety issues. But fires may be underreported because of fear of litigation or bad publicity.

“Virtually all surgical fires are preventable,” said Mark Bruley, vice
president of accident and forensic investigation for ECRI, which has
been tracking operating-room fires for 30 years. He blames the
persistence of the problem on the slow migration of best practices
across the hospital industry.

Most surgical fires involve the ignition of concentrated oxygen by
electrosurgical tools used in upper-body procedures, where patients
receive the highly flammable gas through face masks and nasal devices.
But a growing number are linked to the ignition of alcohol-based
antiseptics.

Solid numbers on the incidence of operating-room
fires do not exist. ECRI's latest estimate of 240 operating-room fires
each year between 2004 to 2011 was revised down from earlier estimates
of 650 fires a year between 2004 to 2007.

While that suggests there has been improvement, studies of anesthesia
malpractice claims suggest there's been a rise in incidents. “There is
an inherent problem in preventing relatively rare events,” said Dr. John
Clarke, clinical director of the Pennsylvania Patient Safety Authority.
People think “it is not likely to happen to you in particular,” he
said.

I was surprised and contacted a patient safety expert who replied, "No one believes it can happen to them, so they cut corners."

That seems to be the case in lots of places. From the article:

Many of the best fire-safety practices developed in recent years stem
from the work at Christiana Care Health System, Newark, Del., after two
patients caught fire in operating rooms within eight months in 2003.

They
pioneered their own process, which involves discussing the risk of fire
during the scheduled time-out before surgery. The hospital hasn't
burned a patient since.

Protocols like Christiana's have been
widely disseminated. Yet, Christiana says it still get calls several
times a month from hospitals that are just starting to implement a
system. “It's a bit of an uphill slog,” said Dr. Kenneth Silverstein,
chairman of Christiana's department of anesthesiology. “The bottom line
is, in order to have a culture of safety in your institution, you have
to get people behind it.”

Sounds familiar. We saw (and still see) hospitals go through the same slow process with central line infections, ventilator associated pneumonia, and other infection-related problems. Maybe now it's time to yell, "Fire!"

I really don't want to write more about surgical robots, but you folks out there keep sending good material. Here's an article by a surgeon on ThirdAge.com "debunking the myths about robotic surgery."

Let's look some assertions:

The robotics technology is expensive and the whole surgical team has to
be trained, which can add to the cost. But there’s also a tremendous
savings compared with traditional surgery because the patient is out of
the hospital more quickly and there are fewer complications.

Many times, the robotics-assisted procedures can be done much more
quickly, so there’s less risk simply because the duration of the
procedure is shorter. You also have the smaller incisions, and less
bleeding, factors that reduce the risks.

This kind of fast and loose talk is a discredit to the profession. I wish there were an agreement that we would rely solely on sound research studies instead of this anecdotal tripe.

Just by casual observation, I have asserted that a hospital was more
likely to acquire a surgical robot if a nearby competitor hospital had already done so. But this was an untested conclusion, based on viewing websites and highway signs, particularly from community hospitals, like above. So I was intrigued to see this great article by Huilin Li (Department of Population Health, New York University) and others in Healthcare. From the abstract:

Background

The surgical robot has
been widely adopted in the United States in spite of its high cost and
controversy surrounding its benefit. Some have suggested that a “medical
arms race” influences technology adoption. We wanted to determine
whether a hospital would acquire a surgical robot if its nearest
neighboring hospital already owned one.

Methods

We
identified 554 hospitals performing radical prostatectomy from the
Healthcare Cost and Utilization Project Statewide Inpatient Databases
for seven states. We used publicly available data from the website of
the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale,
CA) combined with data collected from the hospitals to ascertain the
timing of robot acquisition during year 2001 to 2008. One hundred thirty
four hospitals (24%) had acquired a surgical robot by the end of 2008.
We geocoded the address of each hospital and determined a hospital's
likelihood to acquire a surgical robot based on whether its nearest
neighbor owned a surgical robot. We developed a Markov chain method to
model the acquisition process spatially and temporally and quantified
the “neighborhood effect” on the acquisition of the surgical robot while
adjusting simultaneously for known confounders.

Conclusion

There
is a significant spatial and temporal association for hospitals
acquiring surgical robots during the study period. Hospitals were more
likely to acquire a surgical robot during the robot's early adoption
phase if their nearest neighbor had already done so.